Impact of cross-sectoral approach to addressing konzo in DRC

Marie-Morgane Delhoume is
an agricultural engineer
specialising in agro-development
of tropical regions. She
led the 2011 impact study of
ACF-USA’s Integrated
Programme for the Eradication of Konzo in the
Territory of Kwango in DRC.

Julie Mayans is an agricultural
engineer, specialising in food
security and rural development
programme management. She
was the ACF-USA Food Security
and Livelihoods Coordinator
for the ACF-USA DRC mission.

Muriel Calo is the Senior Food
Security & Livelihoods Advisor
for ACF-USA who provided
technical support to the ACFUSA
DRC mission.

Camille Guyot-Bender is the
Technical Programmes
Assistant for ACF-USA.

Special thanks go to the whole of the ACF project
and study team and the communities who
participated in the study. Thanks to those who
provided peer review of the article, namely
Nick Radin of ACF, Marie-Sophie Whitney of
ACF and Dr. J. Howard Bradbury of the
Australian National University. The funding
support of the European Union (EU) Food
Facility Programme is gratefully acknowledged.

From December 2009 to October 2011,
Action Against Hunger (ACF-USA)
implemented a 22-month long intervention
in the Bandundu province of
the Democratic Republic of Congo (DRC)
addressing several factors underlying the
konzo epidemic affecting the population of
Kwango district (see Figure 1). The ‘Integrated
Programme for the Eradication of Konzo in the
Territory of Kwango in DRC’ project was
financed by the European Union (EU) Food
Facility. It aimed to eradicate the disease
through a cross-sectoral approach that focused
on nutrition education and training, dietary
diversification, improved water access and
agricultural processing. A total of 22,000 households
are estimated to have benefited from
these activities. The project was implemented
in 396 villages in the Territory of Kwango.

Prior to implementing the project, ACF
conducted a baseline study1 in collaboration
with the Minstry of Health (MoH)’s
PRONANUT or Programme National de
Nutrition in DRC in 113 villages, across 51
health areas and 11 health zones. A total 2,388
suspected konzo cases were screened and 2,218
were confirmed. The average incidence of
konzo was 1.07%. Among confirmed cases,
83% were located in savannas, 1% in hillside
areas and 4% in valleys. Kahemba health zone
was found to harbour the highest number of
confirmed cases (1,639), and placed among the
top three zones for incidence (2.08%) largely
due to its density of population and associated
risk factors.

Processing mill

Local beliefs and traditional customs were
found to influence strongly the incidence of
konzo in the area. Local eating customs that
favour the male head of household were noted
as likely contributors to heightening the exposure
of women and children to konzo. There
was a widely held belief that the disease is
caused by black magic, while knowledge of the
food-related origins of the disease was low.

Households rely primarily on agriculture
for food and have limited dietary diversity.
Cassava is cultivated as a main crop, with
maize, groundnuts and beans as secondary
crops. Diverse environmental factors, such as
soil fertility and soil water retention, affect the
quantity and quality of harvests.

Water access is a critical factor in konzo incidence,
with access limited by both distance to
and seasonality of water points. Water coverage
levels are very low, with 5% coverage in the
Feshi health zone and 4.3% in Kajiji.2 Due to
these challenges, cultivators in rural areas most
often prefer to soak the cassava directly on
river banks, in ponds or in swampy areas in
order to avoid carrying heavy quantities of water back to their homes. In semi-urban areas,
people prefer to ret the cassava in their homes
(in buckets or barrels) due to the likelihood of
theft if the cassava is left overnight in a public
area. This practice can be hazardous as the
quantity of water available in urban areas is
often insufficient, and this often leads to not
changing the water on a daily basis during the
retting process which greatly increases the risk
of cyanide intoxication.

Implementation strategy

The programme strategy sought to address
directly the range of critical factors related to
konzo disease that were identified in the baseline
survey. These included knowledge of and
attitudes towards the disease, limited agricultural
and dietary diversity, low water access
and poor knowledge and practices around
cassava processing. The strategy also aimed to
address indirectly the high rates of malnutrition
seen in konzo cases (25.8% global acute
malnutrition (GAM) prevalence in konzo
affected children less than 18 years old, 69.3%
of GAM in konzo affected adults). Project
design used a cross-sectoral approach to
address underlying factors in a holistic and
integrated manner.

Community outreach, mobilisation and
education

ACF employed a community outreach and
mobilisation approach through the creation of
community cells as a forum for discussion on
konzo and nutrition. These served as launch
pads for a broadly based educational campaign
on konzo, which also extended to churches,
schools, training of local health professionals,
community volunteers and leaders, traditional
authorities, etc.

Information, Education & Communication
(IEC) materials on food processing and preparation,
nutrition and konzo were developed in
collaboration with the PRONANUT, including
posters, brochures, training modules and other
material with graphic illustration and supporting
text in Lingala, Kikongo and French
languages. Posters were distributed for display
in places such as public areas, religious sites,
health centres, schools and administrative
offices. Radio messages incorporating songs
and stories were crafted for broadcasting on
two local radio stations. To complement, ACF
organised 154 mass sensitisation sessions in
churches, mosques and schools.

Across the intervention zone, 35 senior MoH
staff, 429 community leaders and authorities,
and 1052 community volunteers were trained on the tools and in turn, used their knowledge
and skills to pass the message more broadly
across the population. Each community volunteer
presided over a community cell or served
as secretary to the president. Skilled in community
mobilisation and training, this individual
would facilitate community dialogues on a
weekly basis and ensure regular reporting to
the local health centre. Each cell had use of an
office space and comprised one committee president,
one secretary and two advisors. The
creation of 647 community cells across 395
villages offered a setting for demonstration,
discussion and exchange. These cells gathered
members from a local neighbourhood or village
hamlet and numbered roughly 45 members
each.

What is konzo?

Konzo is a sudden epidemic spastic paraparesis (paralytic) disease which leads to a permanent paralysis
of the affected person’s lower limbs. It is a neurological ailment triggered by sustained dietary exposure
to the cyanide present in improperly processed cassava. Konzo itself is not fatal, but its debilitating
effects heighten the risk of morbidity and mortality from other diseases. Its disabling effects result in
practical, social and economic challenges for individuals and families of individuals living with the
limited physical capacity induced by konzo. The disease usually appears in clusters within households,
as exposure comes from food consumed as a family meal.

Overall, vulnerability to konzo is heightened by the combination of low protein intake (associated with
low dietary diversity), poor soil conditions (which favour the cultivation and consumption of bitter
cassava varieties high in cyanide), and a lack of sufficient water resources for thorough processing.

Cooking demonstrations were organised at
the level of each cell to complement discussions
around balanced diets and promotion of
kitchen gardens. ACF organized 1,808 demonstrations
and volunteers organized another
2,600 demonstrations for cell members, averaging
four demonstrations per cell. Improved fufu
recipes based on mixed cassava and maize flour
were introduced in the cooking demonstrations.
ACF also extended practical support to
the groups through provision of tanks and mills
for cassava retting and processing.

Sensitisation being
carried out on konzo in
a mosque in Kahemba

Agricultural and hydraulic infrastructure
support

As part of crop and diet diversification activities,
ACF introduced cultivation of improved
varieties of two food crops over two successive
agricultural seasons, niébé (cowpea) varieties
Vita 7 and Muyaya, and sweet cassava varieties
TME119, Mwuazi, Nsasi, Disanka and Butamu.
Cultivated in other parts of the DRC, their introduction in Kwango was aligned with local
agro-ecological conditions and intended to
support increased consumption of sulphurbased
amino acids contained in leguminous
foods (to counteract high levels of cyanide in
the diet) and to complement consumption of
traditional cyanide-heavy bitter cassava varieties
with varieties low in cyanide. ACF
delivered technical training on agricultural
techniques to the 12,500 beneficiary households
of food crop support. The bulk of the sweet
cassava cuttings distributed in the framework
of the project were produced by local agromultiplier
associations partnered with ACF.
ACF also supported the installation of 13
village based mills to increase access to maize
and cassava milling services and improve the
quality of the flour.

In order to increase water access, ACF implemented
a variety of hydraulic constructions:
public retting tanks to process cassava, boreholes,
springs, rainwater harvesting systems
and piped distribution networks. To encourage
the participation of the community, the tanks
established were given a supervisor who
assigned a management team. Although the
management committee owned the tanks,
anyone in the area could use them in exchange
for a small fee.

Cooking demonstration

Impact study

The impact study was conducted in six of the
eleven health zones targeted by the project
along two main axes - the western axis (Kenge,
Boko, Popokabaka, Wamba Luad) and the eastern
axis (Kahemba and Kajiji) (see Figure 1).

A stratified sampling approach was used,
with six of eleven intervention health zones selected purposively and 40 of 395 intervention
villages selected randomly. In each selected
village, six beneficiary households were
randomly selected to participate in household
surveys (234 in total). Of these, 76% had participated
in community cells and 24% had not.
Household surveys were supplemented with
information from key informants and focus
groups.

Findings

Knowledge and attitudes on konzo and
nutrition

Changes in knowledge at endline compared to
baseline suggest that community outreach and
education activities were effective in challenging
long held local beliefs on konzo and
nutrition. At project baseline, 74% of sampled
population thought that the disease had a metaphysical
or black magic origin; at endline this
proportion had dropped to 7%. Eight-eight per
cent of the sampled population correctly noted
the food-related causes of konzo at endline,
while 3% indicated a viral cause and 8%
reported they did not know the cause.3 This
finding represents the strongest indicator of
project impact.

Participation in a cell was found to be correlated
with knowledge of the food-related cause
of konzo. In addition there was a strong inverse
correlation between both ‘participation’ and
‘lack of knowledge’, and ‘participation’ and
‘belief in a metaphysical origin’. These findings
reveal the importance of outreach and education
activities delivered both within the
community cells and directly by ACF.

Similar results were found regarding knowledge,
attitudes and practice on prevention
strategies. In particular, messaging encouraged
appropriate processing of cassava and inclusion
of increased levels of protein in diets through
incorporation of maize flour into fufu preparation
and legumes (pulses) in the diet. At
baseline, households reported utilizing maize
flour in their fufu preparation in only a few
cases where milling services were available,
while millet flour was used in the north eastern
Feshi territory. Knowledge of prevention strategies
linked to food preparation and dietary
diversity was limited. At endline, a majority
(78%) of respondents indicated that a diversified
diet + correct cassava processing would
prevent konzo, while 7% believed that witchcraft
was the cause of the problem and 8% did not know. At endline, 47% of the population
reported preparing fufu with mixed cassava/
maize flour. Nearly half (45%) of respondents
prepare their fufu exclusively with cassava flour
while 8% combine cassava and millet flours.

Lack of access to maize milling services
explains 77% of surveyed cases of non-incorporation
of maize flour into fufu, which are
concentrated on the western axis of the intervention
zone (Kenge, Boko, Popokabaka and
Wamba Luadi). Just 3% of cases justified the
exclusive use of cassava flour on the basis of
food habits, indicating that the messages
around fufu preparation were well appropriated,
but cannot be translated into practice
largely due to practical constraints.

Food stocks and dietary diversification

New varieties of niébé were largely accepted
across the intervention zone and integrated into
the diet, notably on the eastern axis (Kahemba,
Kajiji) where populations were unfamiliar with
niébé. Sweet cassava was readily integrated into
both east and west Kwango, with results showing
a general increase in the intercropping of
both bitter and sweet varieties, as well as
increased cultivation of sweet varieties on their
own. In Kahemba, the bitter cassava variety
Mwambo is widely cultivated and consumed to
the exclusion of other varieties, whereas both
bitter and sweet varieties are cultivated and
consumed along the western axis. However,
sweet varieties were well accepted in Kahemba
as they offer shorter processing times and are
immediately consumable.

Food stocks at baseline (May 2010) and
endline (August 2011) were assessed (see
Figure 2). The results reveal a notable improvement
in both the overall stocks and the
diversity of food items held by households,
including pulses. The surveys were not conducted at the same time of year, which
would have ensured the greatest comparability,
however neither one was carried out in the
post-harvest period when differences in food
availability are significant. The positive trend in
diversity and volume of household food stocks
may be attributed to project impact, in particular
the IEC activities around balanced diets and
food processing and preparation, as well as
external factors such as climate, crop disease
and seasonal fluctuations.

Cassava retting techniques and water
access

Water source in
Kigwangala

Knowledge of community leaders and member
households of community cells regarding
cassava retting and drying techniques were
assessed before and after training. On the
recommended length of time to ret and dry
cassava, the share of community leaders
correctly reporting optimal length (4 days)
increased from 60% at baseline to 99% at
endline. Member households showed a similar
level of knowledge at endline but stated
constraints around access to processing sites
and water quality in applying the practice.
At endline, a majority of households (92%)
indicated they were processing cassava in
rivers or ponds, with a minority using cassava
retting tanks (4%) or containers at home (4%).
At baseline, utilization of home retting techniques
– that rely on prolonged use of the same
water, saturated in acid and less effective in
cyanide detoxification – was relatively common
in urbanized sites (9% in Kahemba, 10% in
Popokabaka, 5% in Kenge). At project end, it
was noted that these practices have been largely
abandoned, partly due to ACF’s implementation
of peri-urban water points.

At the end of the project, households
reported soaking cassava an average of 3.4
days, a significant increase from the average of
2 days noted at baseline across the intervention
area. Constraints to optimal practice include
the risk of theft of tubers at open river and
pond sites, as well as dietary and income pressures. Impacts on cassava retting practice from
ACF’s establishment of communal retting tanks
maintained and watched over by community
groups are not yet known as the infrastructures
were in process of installation at the time of
survey.

Konzo incidence

A surveillance system for screening and identification
of konzo cases in Kahemba health zone
was established by the local health structure in
2009, with annual caseload an estimated 1,300
individuals in 2009. MoH educational activities
and ACF integrated activities on konzo were
launched in early to mid 2010, with a marked
decrease in cases (fewer than 200) recorded that
year. A further reduction in caseload between
2010 and 2011 was noted during the critical
months of June, July and August (dry season)
with 47 new cases recorded in 2011(see Figure
3). This represents an 84% reduction in incidence
between 2010 and 2011. The greatest
reduction in new cases was observed among
the under 5 years age group. Note that the
observed reduction in konzo incidence cannot
be attributed solely to project activities as
numerous external factors are likely to influence
this outcome.

The results on reduced incidence are corroborated
by ACF analytical findings of urine and
cassava flour sample cyanide content, taken
from 100 randomly selected beneficiary households
at project endline (see Figures 4a and 4b).
A 50% reduction in flour samples presenting
medium to high cyanide levels (20 to 40 ppm)
was observed compared with baseline, as well
as a 16% reduction in thiocyanate levels in urine
samples (>300µmol). These reductions translate
into a slightly lower risk of developing konzo.

Observed reductions in cyanide content of
baseline and endline samples are similarly
attributed to numerous external factors such as
seasonality, migration, agricultural production,
health condition, diet composition, water availability,
as well as project impact.

Cassava retting
tank in Feshi

Conclusions and recommendations

ACF’s multi-tiered community outreach
and education strategy proved effective in
the diffusion of information on a large
scale. The community cell approach
allowed for a deep, sustained and broad
based appropriation of messages and activities
around nutrition education and konzo
that would not have been possible if only
traditional IEC methods and materials had
been utilised. Placing community members
in leadership positions to carry out sensitisation
allowed local taboos to be effectively
mitigated through open discussion. This
approach also permitted the affected population
to control the educational process,
encouraging better appropriation of
messages, knowledge transfer and behaviour
change. Impacts achieved through the
community outreach and education
approach were reinforced by improved
access to water, agricultural processing
infrastructure and opportunities to diversify
diets.

Based on these findings, ACF-USA issued
the following key recommendations:

Continued promotion of messaging by
community cells and MoH staff

Continued epidemiologic surveillance
of incidence of konzo cases by MoH in
collaboration with local partners with
a focus on high concentration areas